[Endoscopic extraperitoneal radical prostatectomy. Results after 300 procedures]. / Die endoskopische extraperitoneale radikale Prostatektomie (EERPE). Ergebnisse nach 300 Eingriffen.

During the last decade laparoscopy has become the standard technique in the urologist's armamentarium due to constant technological advancements and refinements. Laparoscopic radical prostatectomy (LRPE), although technically demanding and associated with a considerable learning curve, has become the operative procedure of choice for patients with clinically localized prostate cancer in selected and specialized urologic centers around the globe. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal organ of the prostate. The principal disadvantages of LRPE are potential intraperitoneal complications. Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimally invasive surgery as it overcomes the limitations of LRPE by the strictly extraperitoneal route of access. Based on our growing experience with this procedure we introduce several technical modifications, improvements, and refinements including a nerve-sparing, potency-preserving approach (nEERPE) in an effort to further improve this minimally invasive procedure. We report our short-term follow-up results after 300 procedures. The mean operative times were 115 min without and 150 min with lymph node dissection, in total 140 min (range: 60-260 min). There was no conversion and the transfusion rate was 1.3%. There were three early reinterventions (two bleeding and one hematoma) and five late reinterventions (four symptomatic lymphoceles and one colostomy due to a rectal fistula). Pathological stage was pT2a in 54 patients (18%), pT2b in 87 patients (29%), pT3a in 115 patients (38.3%), pT3b in 40 patients (13.3%), and pT4 in 4 patients (1.3%). Positive surgical margins were found in 9.2% (13/141) of patients with pT2 tumor and 30.3% (47/155) of patients with pT3 tumor. The mean catheterization time was 6.9 days. Six and twelve months postoperatively 86.3 and 89.6% of the patients were completely continent; 9.2% of patients needed 1-2 pads per day and 4.5 and 1.2% of patients needed more than 2 pads per day, respectively. Short-term oncological and functional results of EERPE are at least as favorable as in LRPE while operative times are shorter and complication rates are low. EERPE is a technical advancement because it combines the advantages of a totally extraperitoneal access with the advantages of a minimally invasive procedure.

Normal hemodynamic parameters do not always predict the presence of a rigid erection: a quantitative assessment of functional erectile impairment.

The purpose was to assess objectively and quantitatively the hemodynamic status and the degree of functional erectile impairment in a group of impotent patients. A clinical study was designed, incorporating pharmacocavernosometry (to evaluate arterial and veno-occlusive function) with axial buckling forces and penile geometry measurements in a group of impotent patients. The pressure gradient between the intracavernosal pressure associated with the presence of penile axial rigidity and the equilibrium intracavernosal pressure was calculated (axial rigidity gradient, ARG); such methodology allowed a quantitative characterization of functional impairment, as ARG expresses the intracavernosal pressure increase necessary to achieve axial rigidity and therefore potency. Penile geometry characteristics were also expressed by calculating the penile aspect ratio (diameter/length, D/L). In 83 consecutive patients tested (mean age 42.89+/-9.96), rigidity occurred at intracavernosal pressures between 50 and 100 mm Hg. A conversely proportional relation was noticed between penile aspect ratio values and the intracavernosal pressure associated with rigidity values, clearly demonstrating the important functional role of penile geometry. ARG demonstrated a wide range of values (3-69 mm Hg), reflective of the severity of the erectile dysfunction on each patient. Half (50.6%) of the patients had ARG values < or =20 mm Hg, indicative of minimal and minimal-to-moderate erectile impairment, while 20.48% had ARG between 21-30 and 28.92% >30 mm Hg, indicative of moderate and severe erectile dysfunction (ED) respectively. In all, 6% of the study group, all of them with primary ED, ARG <20 mm Hg had normal hemodynamics, but low penile aspect ratio values indicating that penile geometry may be the cause of insufficient rigidity. Hemodynamic integrity is the most critical, but not the only determinant of penile rigidity, as erectile impairment may be noticed in patients with normal arterial inflow and corporal veno-occlusive function. In such cases, unfavorable penile geometry should be considered as the possible etiological factor of impotence.